Making sense of pain through science and stories. Bridging the gap between patients and health professionals.

Pain doesn’t always equal injury: Thoughts on acute and chronic pain

There are a number of things I’ve been wanting to write about but I always have trouble knowing where to start (I have a tendency to want to give you guys EVERYTHING ALL AT ONCE). So I’m going to start chipping away at them in small doses, starting with some clarification on what pain is and what it isn’t.

Today I want to talk about a common misconception about pain: that pain equals injury.

A little bit about pain

When we get hurt and have an acute injury (like a sprained ankle or a broken bone), our bodies are really good at protecting the injured body part through a series of biological mechanisms.

These mechanisms are in place to bring lots of blood and nutrients to the area that is injured and can lead to some discoloration and swelling. That swelling is a good thing: it immobilizes the joint or area that is hurt so that it has time to heal, essentially our body’s own cast.

Understandably, we are very protective of an injured body part. Our brains accurately interpret that there’s a threat to the system (we’re the system) and takes measures to protect the system (us).

Back in the old days, before modern medicine, an injury could mean death. If we couldn’t walk, we couldn’t search for food or leave a dangerous area.

So this signal of PAIN! is an indication of threat or danger, it causes us to stop, assess the situation, and take precautionary measures before doing any further damage to the self.

But…pain can be weird

If we break a bone in our ankle we might experience a great deal of pain. It could also be harmful to keep applying pressure to that foot, so we’d likely stop and tend the injury.In this case, pain indicated an injury took place.

But pain can also be delayed (or not there at all), even in the presence of injury. If that same broken or sprained ankle injury occured during a dangerous situation, say being chased by a lion, or during a big game, the pain may not be felt until after the danger had passed or the game was over (allowing for escape or securing a win). Context matters!

In that case, injury DID NOT equal pain.

What about pain with no injury? Yep, that can happen, too. Think about stepping on a rock or a Lego in barefeet, it’s freakin’ painful! Or stubbing your toe on a piece of furniture. Even though it may have been just as painful as the broken ankle initially (we’ve all been there, right?), it doesn’t lead to injury, there isn’t likely to be any damage at all.

The pain goes away, we know that it’s not big deal, and we can continue walking along and applying pressure to that foot.

In that case, pain DID NOT equal injury.

So pain doesn’t always equal damage or injury, this is especially true for chronic or persistent pain

Pain is an output of the brain: a warning system telling us to slow down and assess the situation and maybe change up our behaviors a bit to mitigate the pain.

In the case of the broken ankle, we’re going to want to treat it.

In the case of stepping on a Lego, we’re going to want to pick up the Legos.

Way different ways to reduce pain, but both equally valid and successful in managing future pain.

Immobilization and preventing movement would be way overkill in the Lego incident, that’s obvious. But what about the broken ankle?

It needs medical treatment, number one. But even that treatment looks a bit different nowadays than it did just a decade ago.

We used to think that not moving and bed rest were the best thing for pain and injury, but we’re learning that’s not always (or even often) the case.

Now, many times the doctor won’t prescribe bed rest for an acute injury but will instead encourage us to move as much as possible within our pain-free range of motion.

There is much more emphasis on keeping moving, as opposed to keeping still

In many cases, bed rest can even be detrimental to our recovery. Rather than just limiting movement in the injured body part to allow it to heal, bed rest means we are limiting movement in ALL body parts, and that’s no bueno.

Movement is necessary to maintain overall muscle strength and endurance, range of motion in our joints that allow, to bring necessary nutrients to our muscles, vessels, organs, and joints, and to keep all of our systems (from digestion to cardiorespiratory to immune to endocrine) humming along.

Movement is good. Even in the presence of pain.

When pain becomes chronic or persistent

Chronic and persistent pain are a bit different than the acute pain laid out above, but there are also some similarities. Sometimes pain can persist, long after an injury heals. There is a saying that the “the tissues heal but the nervous system remembers”.

But just like in the acute pain examples, there can be pain present when there was never an injury to begin with. It’s a danger signal that is sort of a false alarm and the signal just doesn’t shut off.

In either case, injury or no injury, pain can be present or persist for many different reasons. We are learning more and more every day in the realm of pain science what is going on in chronic pain, and while there is still much we don’t know, there is much that we do that we can use.

What we do know is that chronic and persistent pain are most often NOT associated with an injury or tissue damage, even if it began with an injury. Pain is an output of the brain that indicates it has detected some threat to the self. It is a danger signal, but the signal might be off and likely isn’t reflective of the state of the tissues.

Chronic pain is complex

Pain is the result of many different factors; what are called biopsychosocial factors.

Biological factors

Some people with chronic pain may have hypersensitive nervous systems (that whole, the tissues heal but the brain/nervous system remembers adage) or their immune system may be reacting in a way that is causing them pain.

The good thing is, that we can retrain the brain and the nervous system to not be so sensitive. Or we can target the immune system with effective treatments if that’s a driver of pain.

Psychological factors

You know how when we’re really nervous, our palms and pits can sweat and our heart can race, and our mouth can water? That’s an example of how what we’re thinking and what we believe can affect our physiology. Or how when we’re stressed, our cortisol levels go up? That’s the influence of our psyche on our hormones.

The same can go for pain, the mind and body are one, what one does will always affect the other and neither can act alone. This does not mean that pain is “all in our head”, it’s not imagined or brought on by ourselves.

Pain is very real. All pain.

One thing we need to get away from is the belief that anything ‘psychological’ means crazy or imagined. It doesn’t. (read more here on how harmful the phrase ‘it’s all in your head’ can be.)

What this does mean, is that sleep deprivation, stress, depression, anxiety, catastrophizing (believing the worst is going to happen), fear of movement (a lot of pain patients are afraid to move for fear of doing damage or worsening their pain), negative thoughts, and a whole host of other things can make pain feel worse or flare-up.

The good thing is that it works the other way, too. When we work on those things – when we prioritize sleep, when we manage our stress or anxiety with mindfulness or breathing exercises or relaxation methods, if we can manage our depression with physical activity and social interaction – we can make our pain better, too.

Social factors

The social factors involve everything from our cultural conditioning (think of how parents react to skinned knees, the look on the doctor’s face as he looks at our MRI, or of seeing enduring pain as a sign of strength and honor, among a gazillion other things) to our relationships.

Pain can often make people withdraw, which can lead to depression (which can lead to a vicious cycle of worsening pain and worsening depression), or fail to engage in life in ways they want to.

Some of this is because they aren’t able to communicate their pain, or they don’t understand what pain is (and isn’t), or they feel they are a burden, or they feel stigmatized because they have an “invisible” condition that people discount or dismiss because they don’t understand it and can’t ‘see’ it.

But again, the good thing is that pain can lessen when we reengage with life, when we foster relationships with loved ones and friends, when we socialize again (pain groups can be great for this!). When we love and are loved.

Pain does not equal injury. And injury does not always equal pain. Pain and injury are two wholly different definitions.

Chronic and persistent pain do not always mean injury.

Chronic pain can be a diagnosis in and of itself. There does not have to be an underlying injury or structural damage that is causing the pain.

There is no definitive scan or x-ray or test that can identify the cause of most chronic pain, so pain patients are often made to feel that “since there is no injury, there should be no pain”.

That’s rubbish.

Pain equals pain.

Though it may seem that because pain is so complex it’s helpless, that’s far from the case!

It’s a GOOD thing that we now understand that there doesn’t have to be damage or injury for there to be pain, because that means we can stop freaking looking for it!

Instead, we can focus our energies and attentions on all the actions we can take to manage and even overcome our pain.

We can work to figure out which factors are contributing to our pain (are we not moving enough because we’re fearful? not sleeping enough? catastrophizing too much? worrying and anxious about the pain? confused about what the pain means? withdrawing from loved ones? is our nervous system on overdrive? is our immune system down?).

We can retrain our brains to understand that movement is safe. That it is not only ok, but downright beneficial and will help us to manage our pain so we can live a full, happy, and active life. (my next post is going to be specifically about this!).

We can retrain our mindset, to accept that we have pain but that that’s ok because THERE IS SOMETHING WE CAN DO ABOUT IT. Lots of somethings.

We can love and be loved. We can move. We can be mindful. We can sleep well. We can eat well. We can get creative. We can move some more. We can get outside. We can play. We can pursue the things that matter to us. We can live our lives.

We ARE deserving of it. Our pain does not make us less. It does not make us unworthy. It does not make us a burden. It is just a part of us at this moment, and that is ok.

I went a bit long folks, and I could go on for days! I appreciate your attention if made it this far.

And for some evidence based pain science from Paul Ingraham, check out painscience.com

A couple notes:

This is a blog, not medical diagnosis or treatment and shouldn’t be interpreted as such. What it should be interpreted as is that WE have the power to take our health and happiness into our own hands. We can take actions to help manage and overcome our pain.

The Lego image is from: www.sodahead.com

As always, I’d love to hear from you. And if you liked what you read or think someone can benefit from reading it, please share via the little envelope icon below, that will let you share it on social media or email it directly to someone.

Thanks for your excellent blog. Looking forward to more
Would you be interested in teaching a course in Wexford sometime? If you can’t can you suggest someone that could? Anne Dempsey Chartered Physiotherapist. Member of south eastern branch committed. We are currently trying to organise some good courses. 0876833655

Hi Alex, thank you for questions. There are both immune influences on pain and pain influences on the immune system. My first exposure to the neuroimmune aspects of pain was through the work of Lorimer Moseley and David Butler in their Explain Pain and Protectometer books. Are you familiar with their work? it is largely about bioplasticity and the changes that take place in our biological systems with pain and also the ability to use bioplasticity to our advantage. While primarily about the overprotectedness of the nervous system in ongoing pain they also discussed the role of various systems, such as respiratory, motor, immune and endocrine systems as well as thoughts, feelings, language and cognition.

David Butler also wrote the Sensitized Nervous System which also includes immune function and changes and Adriaan Louw and Emilio Puentedura talk about it in Therapeutic Neuroscience Education. There has been much more learned in the years since these texts were written, too.

Robert Sapolsky is a great resource for reading about chronic stress and how it affects our systems (including immune) and steps we can take to mitigate it.

Thank you for your kind words, Anne. I would love to teach a course in Wexford some time! I live in the US, though, so I’m not readily available to do so in person. I would love to explore a virtual option if you are so inclined and we are a good fit for one another. I have recently cofounded a nonprofit organization that puts on workshops and retreats and online workshops are something we are exploring. If you could let me know more about the type of courses you are interested in hosting I could also reach out to some of my international peers to see if there is someone that would meet your needs.

Thank you so much for this well explained article. I myself have been diagnosed with CRPS, Which totally encapsulates everything you see here about chronic pain. I’m glad I discovered that I had much influence over my pain within a few months of my diagnosis and it is now largely under control. My heart breaks for those who are spiraling in desperation, letting their pain rule and ruin their lives. When I explain what is wrong with me and people ask if it’s all in my head, I say “A part of it is, but it is definitely NOT in my imagination!!”

Hi Adrienne. Thank you so much for taking the time to leave this message and for sharing a bit of your story, it means so much to me. My heart breaks for those who are still spiraling, too. I hope that people like us who share our stories can give a bit of hope to others! It is wonderful to hear that your CRPS is largely under control. Living well with pain is possible. Thanks so much for connecting!

I cannot even begin to tell you how glad I am to have found you and your blog on pain and it’s complexities. After 20 years of intermittent pain and the last 3 years of permanent pain, I have hit the depths of despair and the lowest points of my life… but all the while still searching for the positives and for hope. Your blogs are a window to my soul…. thank you 🙏

Thank you so much for taking the time to leave me a message, Hilary, it means so much to me. I’m sorry that you’ve lived with pain for so long and have hit the depths of despair, that is such a hard place to be. I’m glad you’ve found some positive amongst the lows, some light amidst the darkness. You are not alone in this ❤